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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625430
Report Date: 12/12/2023
Date Signed: 12/12/2023 05:35:23 PM

Document Has Been Signed on 12/12/2023 05:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KHUDAINAZAROVA, EKATERINAFACILITY NUMBER:
343625430
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
12/12/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ekaterina KhudainazarovaTIME COMPLETED:
10:30 AM
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On Tuesday, December 12, 2023, Licensing Program Analyst (LPA) Tanya Washington met with Applicant Ekaterina "Kate" Khudainazarova for the purpose of an announced pre-licensing inspection. The visit was conducted in Russian language. All adults residing in the home have obtained the required fingerprint clearances. Applicant plans to operate Monday- Friday from 6 AM to 6 PM. Applicant rents the home and a copy of the rental agreement was obtained to show control of property. Applicant has notified the landlord that childcare will be provided and signed consent form LIC9149 was submitted.

A health and safety inspection was conducted inside and outside the home. This facility is a single story home which has four bedrooms, two bathrooms, garage and fenced backyard. Applicant plans to utilize the fenced backyard for outdoor play and take children to a near by park with the parents permission. The off limit areas of the home will consist of the office, master bedroom/bathroom and garage. Applicant understands that children may never access the off limit areas of the home. Off-limit areas will remain inaccessible to children by closed doors and/or supervision. There are no bodies of water on the premises.

Toxic and hazardous items are inaccessible to children and out of children’s reach. Sharp knives are stored in an upper kitchen cabinet, out of children's reach. Medications are stored in the upper kitchen cabinet. A functioning smoke detector, carbon monoxide and a 2A10BC fire extinguisher were observed in the home. Applicant stated that there are no weapons in the home. LPA advised applicant that all poisons must be locked and made inaccessible to children. LPA discussed all required licensing postings and provided a copy of LIC610A and PUB394- Parents' Rights poster.

Applicant is enrolled in the required Preventative Health and Safety course with the Lead Poisoning Prevention training on 01/10/2024. Current EMSA approved pediatric CPR/First Aid training were verified and expire 09/2025. Applicant is registered to take the Mandated Reporter training through Child Action agency on 12/20/2023.

Applicant was encouraged to maintain supervision at all times. Applicant understands that if an unusual incident occurs, licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC624 shall be submitted within 7 days to remain in compliance. LPA discussed Type A/B citations, open door policy, fire drills, children’s personal rights with the applicant. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care. PAGE 1. REPORT CONTINUES ON LIC809-C

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KHUDAINAZAROVA, EKATERINA
FACILITY NUMBER: 343625430
VISIT DATE: 12/12/2023
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LPA explained to applicant that if they relocate and wants to continue to provide care, they must submit a change of location application and have the new home inspected. Applicant understands that if any structural changes are made to the home, licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an on-limits area, licensing must be notified and LPA must do an inspection before children are allowed in the area. Applicant understand that licenses are not transferable, and once licensed, licensees must live in the home and be present for 80% of the operating hours. LPA reviewed with applicants the LIC 311D (Forms/Records To Keep In Your Family Child Care Homes), children’s forms/records, facility forms/records, and information to be posted.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Continued on LIC809C
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KHUDAINAZAROVA, EKATERINA
FACILITY NUMBER: 343625430
VISIT DATE: 12/12/2023
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed- related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Effective today, 12/12/2023, the facility is issued a provisional license for a maximum of 6 children - no more than three infants or four infants only or 8 children no more than two infants and one child at least age 6 and one child enrolled and attending pre-kindergarten or elementary school.

Upon completion of Preventative Health and Safety training, a regular license will be issued. The provisional license is valid for 90 days, expiring 03/12/2024.

Exit interview conducted and report was reviewed with the applicant Ekaterina Khudainazarova.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
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